have diabetes but do not yet know it. report, Diabetes in New York City: of the diabetes epidemic in NYC and the large disparities in its impact on …

DIABETES IN NEW YORK CITY:
PUBLIC HEALTH BURDEN
AND

DISPARITIES

Diabetes in New York City: Public Health Burden and Disparities

TABLE OF CONTENTS
Letter from the Commissioner Executive Summary Introduction Chapter 1 Prevalence 1-1 Chapter 2 obesity and related Risk factors 2-1 Chapter 3 morbidity: Hospitalizations and end-stage renal disease 3-1 Chapter 4 Mortality 4-1 Chapter 5 Health Care Indicators 5-1 Chapter 6 Diabetes During Pregnancy6-1 APPENDIX A ABOUT THE DATA apxa-1 APPENDIX B NEIGHBORHOOD TABLES AND MAPS apxb-1 references ref-1

Suggested Citation: Kim M, Berger D, Matte T Diabetes in New York City: Public Health Burden and Disparities New York: New York City Department of Health and Mental Hygiene, 2006

June 2007

Dear Fellow New Yorkers: Diabetes is epidemic in New York City Diabetes prevalence has more than doubled over the past 10 years More than half a million adult New Yorkers have diagnosed diabetes and an additional 200,000 have diabetes but do not yet know it Diabetes and diabetes-associated cardiovascular disease are leading causes of death in NYC About two-thirds of people with diabetes die from cardiovascular events This report, Diabetes in New
York City: Public Health Burden and Disparities, captures the devastating effects of the diabetes epidemic in NYC and the large disparities in its impact on different populations This epidemic requires an effective public health response similar to that traditionally associated with communicable diseases Timely and complete population-level data on diabetes and its management are needed to support public health action and track its impact Data compiled by the NYC Department of Health and Mental Hygiene DOHMH over the past few years, summarized in this first edition of Diabetes in New York City, are a good start but do not tell us enough about how well diabetes is being controlled The two recent DOHMH initiatives detailed below will greatly enhance public health surveillance of the epidemic:

As of January 15, 2006, the New York City Board of Health requires most clinical laboratories
to report hemoglobin A1C test results electronically to the DOHMH Laboratory data on A1C, a key measure of diabetes control, are being used to establish the first population-based A1C registry in the nation The registry will enable the DOHMH to give clinicians and patients feedback and resources that
can improve the quality of care and quality of life for New Yorkers with diabetes

The New York City Health and Nutrition Examination Survey NYC HANES, conducted in 2004,
provides data on A1C levels, blood pressure, lipids and smoking prevalence for a representative sample of New Yorkers with diabetes For the first time, estimates on how well diabetes is controlled among NYC adults are available The DOHMH is working to provide clinical tools, diabetes resources and patient education materials to New Yorkers with diabetes and their health care providers Better data will help us provide more timely and more focused resources, and will strengthen our partnership with patients and their health care providers Sincerely,

Thomas R Frieden, MD, MPH Commissioner New York City Department of Health and Mental Hygiene

Diabetes in New York City: Public Health Burden and Disparities

executive summary

espite advances in knowledge of diabetes care and control, diabetes was the 4th leading

Uncontrolled diabetes is the leading cause of blindness, end-stage renal disease and non-traumatic lower extremity amputations in adults

cause of death in New York City NYC in 2003, directly causing
more than 1,800 deaths and contributing to thousands more In the past decade, the prevalence of diagnosed diabetes has more than doubled among adults in NYC Figure 1 More than 200,000 additional adult New Yorkers have diabetes but have not yet been diagnosed This means that approximately 1 in 8 adults has diabetes More than half of adult New Yorkers are overweight or obese, which increases the risk of diabetes
FIGURE 1

Each year in NYC there are more than 20,000 hospitalizations with a principal diagnosis of diabetes

Although the hospitalization rate for diabetes has been stable in recent years, the increase in prevalence reflects a growing number of newly diagnosed, not yet hospitalized people

It is likely that diabetes-related hospitalizations will increase in the coming years

The health care costs attributed to diabetes and its complications are large and growing The annual cost of hospitalizations with a principal diagnosis of diabetes which reflects only a small portion of diabetes-related costs doubled from 1990 to 2003, reaching 481 million

The prevalence Figure 1 of diabetes among adults more than doubled between 1993 and 2004
Diabetes prevalence , ages 18
10
8 6 4

Diabetes disproportionately affects black and Latino New
2

Yorkers, as well as those living in low-income households
0 1993-1995 1996-1998 1999-2001 2002-2004

and neighborhoods These disparities are evident in diabetes prevalence, hospitalizations and mortality, and track closely with patterns of overweight and obesity,
Figure 2

Rates are age-adjusted to the year 2000 US Standard Population and exclude individuals who did not report age Sources: CDC, Behavioral Risk Factor Surveillance System, 1993-2001; NYC Community Health Survey, 2002-2004

and with the related behaviors of physical inactivity and
FIGURE 2

Diabetes and obesity have their greatest impact in New York Citys poorest neighborhoods
Diabetes and obesity have their greatest impact in New York Citys poorest neighborhoods

Low-income neighborhoods Overweight and obesity prevalence Diabetes prevalence Diabetes hospitalization per 100,000 population Diabetes mortality per 100,000 population 61 12 559 37

High-income neighborhoods 47 6 200 16

Low-income neighborhoods higher by 13 times 2 times 28 times 23 times

See Appendix A Percents and rates are age-adjusted to the year 2000 US Standard Population Percents
exclude individuals who did not report age Sources: NYC Community Health Survey, 2003; Bureau of Vital Statistics, NYC DOHMH, 2003; US Census 2000/NYC Department of City Planning

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The New York City Department of Health and Mental Hygiene

Diabetes in New York City: Public Health Burden and Disparities

Executive Summary

unhealthy diet However, neighborhood disparities in diabetes mortality and hospitalization are partly, but not completely, accounted for by differences in diabetes and overweight/obesity prevalence Figure 2 Neighborhood disparities in diabetes morbidity and mortality may be influenced by differences in diabetes severity, access to health care or availability of healthy foods and places to exercise Regular medical monitoring and patient involvement in diabetes self-management can dramatically reduce rates of diabetes-related morbidity and mortality Unfortunately, there is still a large gap between recommended health services and current practices For example, among NYC adults with diabetes: More than one-third did not receive an eye or foot exam in the past year 57 did not get a flu vaccine in the past year 72 have never been immunized against pneumonia 77
do not take aspirin regularly 56 have never taken a diabetes self-management class Some good news is that the majority of adults with diabetes report that during the past year they had a routine checkup, had their blood pressure and cholesterol

levels checked, and were counseled on weight, nutrition and exercise at their last doctors visit However, while 4 in 5 adults with diabetes in NYC report having had at least 1 hemoglobin A1C test in the past year, only 16 of these adults know their A1C level Furthermore, data from the NYC HANES revealed that more than half of all adults with diagnosed diabetes have hemoglobin A1C levels of 7 or greater, indicating that their blood sugar levels are not well controlled In addition, most did not have their blood pressure or cholesterol within recommended levels Poorly controlled diabetes during pregnancy, whether chronic diagnosed before pregnancy or gestational diagnosed during pregnancy, is associated with a higher risk of poor birth outcomes The prevalence of diabetes during pregnancy grew 47 between 1990 and 2003, when it was present in more than 4 of all pregnancies Maternal obesity increases the risk of diabetes during pregnancy The
data in this report illustrate the magnitude of the diabetes problem in NYC and its disproportionate impact on low-income New Yorkers and the neighborhoods where they live

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The New York City Department of Health and Mental Hygiene

Diabetes in New York City: Public Health Burden and Disparities

introduction

New York City, in parallel with the nation overall, is experiencing an epidemic of diabetes driven, in turn, by another epidemic obesity Dramatic disparities are evident, with low-income populations, blacks and Hispanics disproportionately affected Diabetes is a chronic condition characterized by high levels of blood glucose It is caused by resistance to insulin a hormone that regulates levels of blood glucose, inadequate production of insulin, or both There are 3 main types of diabetes: type 1, type 2 and gestational Type 1 diabetes has a peak incidence in puberty, but can develop at any age Type 2 diabetes usually occurs in adults aged 40 and older who have certain inherited and behavioral risk factors, such as a family history of diabetes, or who are overweight, obese or physically inactive However, with the rise in overweight and obesity at young ages, type 2
diabetes is increasingly affecting adolescents Gestational diabetes occurs during pregnancy, when the body is less sensitive to insulin This report presents an overview of diabetes among New Yorkers as reflected in data from surveys, hospital discharge records and birth and death records The chapters are organized around the types of data presented prevalence, risk factors, hospitalizations, mortality, health care indicators and diabetes during pregnancy Within the chapters, data on time trends, demographic patterns and disparities are presented Detailed neighborhood-specific tables and maps are provided in Appendix B This report presents data on adults 18 and older, unless otherwise noted Only statistically significant, robust findings are discussed Rates are age-standardized to the US Standard Population 2000, unless otherwise noted, to allow comparisons among populations within NYC, as well as to national data For a complete description of the data used in compiling this report, see Appendix A Facts and figures alone cannot capture the challenge faced by the hundreds of thousands of New Yorkers living with diabetes Nonetheless, these data serve to illuminate this complex
problem and to guide a comprehensive public health response

The Diabetes Prevention and Control Program strives to improve the quality of care and quality of life for New Yorkers with diabetes, and reduce the burden of diabetes, its complications, and of diabetes-related disparities in individuals, their families and communities The program has a 5-point plan focused on prevention, improvement of diabetes quality of care, education, policy and advocacy, and surveillance and evaluation

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The New York City Department of Health and Mental Hygiene

Diabetes in New York City: Public Health Burden and Disparities

Chapter

PREVALENCE
In 2004, about half a million adults had diagnosed diabetes, and another 200,000 had it but didnt know it– bringing the total number with diabetes to 700,000, or 125 of all New York City NYC adults Figure 1-1 People with diabetes may have mild or no symptoms and often have it for 4 to 7 years before being diagnosed There is no cure for diabetes, but once it is diagnosed, patients and health care providers can take action to control diabetes and reduce the risk of complications see Chapter 5 The rest of this chapter describes the population of NYC
adults who report they have been diagnosed with diabetes
FIGURE 1-1 FIGURE 1-3
Percents are not age-adjusted Source: NYC Community Health Survey, 2002-2004

FIGURE 1-2

Most adults with diagnosed diabetes are age 45 or older
18-24 years old 7,000 adults 1

25-44 years old 76,000 adults 15

65 years old 195,000 adults 38 45-64 years old 229,000 adults 46

Roughly one of eight adult New Yorkers has diabetes
Diabetes prevalence , ages 20
14 125 12 10 8 6 4 2 0 Prevalence is age-adjusted to the 2000 US Standard Population Source: NYC Health and Nutrition Examination Survey Percents are not age-adjusted Source: NYC Community Health Survey, 2002-2004 87 38 9

More than half of adults with diagnosed diabetes are black or Hispanic
Non-Hispanic White 155,000 adults 30
Undiagnosed Diagnosed

Non-Hispanic Black 156,000 adults 31

Other 19,000 adults 4 Asian 38,000 adults 7 Hispanic 143,000 adults 28

Among adults with diabetes, 84 are 45 or older Figure 1-2, and 59 are black or Hispanic Figure 1-3 The citywide age-adjusted prevalence of self-reported diabetes among adults is 9, which is 28 higher than the prevalence in the US overall Figure 1-4 Adults living in Highbridge-Morrisania, Hunts
Point-Mott Haven, Williamsburg-Bushwick and East New York are most likely to report having diabetes Figure 1-5 More neighborhood-level diabetes data are shown in tables and
12 10 8 6 4 2 0 NYC US 9 7

FIGURE 1-4

The prevalence of diagnosed diabetes among adults in NYC is higher than among adults nationwide
Diabetes prevalence , ages 18

Percents are age-adjusted to the year 2000 US Standard Population and exclude individuals who did not report age Source: NYC Community Health Survey, 2002-2004 Source: National Health Interview Survey, 2004

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The New York City Department of Health and Mental Hygiene

Diabetes in New York City: Public Health Burden and Disparities

Chapter 1: Prevalence

maps in Appendix B The prevalence of self-reported diabetes among adults increases considerably with age among both men and women More than 1 in 5 adults aged 65 and older reports having diabetes Figure 1-6 Men are somewhat more likely than women to report having diabetes 10 vs 8 Adults with the lowest household income are more than twice as likely to report having diabetes as adults with the highest household income Figure 1-7 While the causes of disparities in diabetes prevalence are not
fully

understood, economic disadvantage can make it more difficult to access healthy foods and exercise regularly, contributing to disparities in the prevalence of obesity, a major risk factor for diabetes see Chapter 2 Racial/ethnic disparities in diabetes prevalence exist, with the highest prevalence occurring among black and Hispanic adults 12 and 13, respectively In comparison, diabetes prevalence among whites and Asians is 6 and 9, respectively Figure 1-8

FIGURE 1-5

FIGURE 1-7

Diabetes prevalence varies by neighborhood
Diabetes prevalence , ages 18
17 - 31 32 - 69 70 - 96 97 - 129 130 - 169

Diabetes prevalence is highest among adults from the lowest income households
Diabetes prevalence
25 20 15 11 10 5 8 5

HighbridgeMorrisania WilliamsburgBushwick

Hunts PointMott Haven

East New York

200

200 - 599

600

Prevalences are not age-adjusted Source: NYC Community Health Survey, 2002-2004

FIGURE 1-6

FIGURE 1-8

Diabetes prevalence 1-5 Figure increases with
age
Diabetes prevalence
25 20 15 10 5 1 0 1 0 15 13

Diabetes prevalence among blacks and Figure 1-7 Hispanics is more than twice that of whites
Diabetes prevalence
25 22 20 20 15 12 10 5

Male Female

13 9 6

18-24

25-44 Age group years

45-64

Black

Hispanic

Asian

White

Other

Source: NYC Community Health Survey, 2002-2004

Percents are age-adjusted to the year 2000 US Standard Population and exclude individuals who did not report age Source: NYC Community Health Survey, 2002-2004

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Diabetes in New York City: Public Health Burden and Disparities

Chapter 1: Prevalence

A number of studies have suggested that the risk of diabetes varies among Asian populations, with those of South Asian ancestry at highest risk This pattern appears to hold true for NYC adults born in South Asia, among whom the prevalence of diabetes is more than 3 times higher than among those born in East Asia1 Among adults aged 25 to 44, more than half have had diabetes for less than 5 years Not surprisingly, older adults with diabetes are more likely to have had it longer, but more than half of adults 65 and older have had
diabetes for 10 years or less Figure 1-9 The large proportion of recently diagnosed adults will contribute to a growing burden of diabetes complications, which increase in frequency over time Nearly half 46 of adults with diabetes say that their health is fair or poor, compared to 19 of adults without diabetes In addition, adults with diabetes are twice as likely to report that their usual activity was limited by poor health for at least 1 week in the past month Adults with diabetes were also twice as likely to report emotional distress, compared to adults without diabetes Figure 1-10
Adults with diabetes , ages 25
100 24 80 58 60 28 40 21 20 21 0 25-44 45-64 65 46 33 29 39

FIGURE 1-9

More than half of adults with diabetes Figure years or less have had it for 101-8
Duration of diabetes 5 years 5-10 years 10 years

Age group years
Source: NYC Community Health Survey, 2002, 2004

F I G U R E 1-10

Adults with diabetes are more likely to report poor health, emotional Figure 1-9 distress and physical activity limitations than those without diabetes
Adults
60 50 40 30 20 10 0 Report fair or poor health Report limited activity for at least 1 week Report emotional distress 19 15 12 6
46 34

Diabetes No Diabetes

Percents are age-adjusted to the year 2000 US Standard Population and exclude individuals who did not report age Source: NYC Community Health Survey, 2002-2004 Source: NYC Community Health Survey, Spring, Fall 2003

Age-adjusted diabetes prevalence among those age 65 years was 11 for South Asians compared with 3 for East Asians There were too few South Asians surveyed who were 65 and older for inclusion in this comparison

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The New York City Department of Health and Mental Hygiene

Diabetes in New York City: Public Health Burden and Disparities

Chapter

OBESITY
Patterns of overweight/obesity and the related behaviors of physical inactivity and unhealthy diet underlie the increasing prevalence and disparities in diabetes rates Adults with diabetes are 40 more likely to be overweight or obese 1 than those without diabetes Figure 2-1
FIGURE 2-1

AND

RELATED RISK FACTORS

While the prevalence of overweight or obesity is lower in New York City than nationwide 54 vs 65, more than half of NYC adults are overweight or obese, and 1 in every 5 adults is obese Figure 2-2

FIGURE 2-2

Adults with diabetes are more likely to be overweight Figure or
obese than those2-1 without diabetes
Overweight or obesity prevalence
100 90 80 70 60 50 40 30 20 10 0 53 74

More than half of New York City adults are overweight or obese

Figure 2-2

New York City
Overweight 34 Obese 20

Neither 46

Diabetes

No diabetes

Percents are age-adjusted to the year 2000 US Standard Population and exclude individuals who did not report age Source: NYC Community Health Survey, 2002-2004

United States
Overweight 35 Obese 24

Neither 41
Among adults ages 20 and older Percents are age-adjusted to the year 2000 US Standard Population and exclude individuals who did not report age Source: National Health Interview Survey, 2004

Physical inactivity and unhealthy eating may lead to overweight or obesity increasing a persons risk of developing diabetes 80 of adult New Yorkers do not get the recommended amount of exercise at least 30 minutes per day, 5 or more days per week 30 of New York City adults report no leisure-time exercise in the past month 36 report that they did not walk or bicycle at
least 10 blocks while commuting or doing errands in the past month 90 of adults eat fewer than the recommended 5 or more servings of fruits or vegetables per day

Overweight and obesity are defined by an individuals body mass index BMI, which is based on weight and height An adult with a BMI between 25 and 30 is classified as overweight, and an adult with a BMI of 30 or greater is classified as obese The New York City Department of Health and Mental Hygiene

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Diabetes in New York City: Public Health Burden and Disparities

Chapter 2: Obesity and Related Risk Factors

FIGURE 2-3

FIGURE 2-4

Men are more likely than women to be overweight or Figure 2-3every age group obese in
Overweight or obesity prevalence
70 60 50 40 30 20 10 0 40 33 58 44 66 61 62 60

Overweight and obesity and their associated risk factors are Figure 2-4 most common among adults in the lowest income group
Overweight or obesity prevalence
100

Men Women

80 60 40 20 59 55 49

200

200-599

600

18-24

25-44

45-64

Age group years
Source: NYC Community Health Survey, 2002-2004

Persons who report not exercising in past month
100 80

Like diabetes, the prevalence of overweight or obesity rises
with age through age 64 and is greater in men than in women Figure 2-3 The gender difference in overweight/obesity prevalence is driven by greater prevalence of overweight in men, since men are less likely than women to be obese

60 40 20 39 26 17

200

200-599

600

Persons not walking or biking more than 10 blocks in past month
100 80

Overweight or obesity is most common among adults with
60

the lowest household income, and prevalence decreases
40

36 28

with increasing income Adults in the lowest income group
20

are also more likely to report having risk factors associated
0

with overweight or obesity no leisure-time exercise, not walking or biking more than 10 blocks while commuting or doing errands and not eating the recommended servings of fruit and vegetables per day compared to adults in the highest income group Figure 2-4

200

200-599

600

Persons who do not eat 5 or more servings fruits or vegetables per day
100 80 60 40 20 0 94

200

200-599

600

Household income of federal poverty level
Percents are age-adjusted year year 2000 US Standard Population and Percents are age-adjusted to the to the2000 US Standard Population and exclude individuals
who exclud age did not reportindividuals who did not report age Source: NYC Community Health Survey, 2002-2004 Source: NYC Community Health Survey, 2002-2004 Source: NYC Community Health Survey, 2003-2004 Source: NYC Community Health Survey, 2003-2004 Source: NYC Community Health Survey, 2004 Source: NYC Community Health Survey, 2002, 2002, 2004

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The New York City Department of Health and Mental Hygiene

Diabetes in New York City: Public Health Burden and Disparities

Chapter 2: Obesity and Related Risk Factors

Overweight or obesity in NYC also differs by race/ethnicity Nearly two-thirds of black and Hispanic adults are overweight or obese, compared to approximately half of whites and one-third of Asians Compared to their white
Overweight or obesity prevalence

FIGURE 2-5

Overweight and obesity and their associated risk factors Figure 2-5 are most common among blacks and Hispanics

counterparts, blacks and Hispanics are also more likely to report having risk factors associated with overweight or obesity no leisure-time exercise, not walking or biking more than 10 blocks while commuting or doing errands and not eating the recommended levels of fruit and vegetables per day
Figure 2-5

100 80 64 60 49 40 20 0 33 64 52

Black

Hispanic

White

Asian

Other

Persons who report not exercising in past month
100 80 60 41 40 20 0 31 22 34 27

Black

Hispanic

White

Asian

Other

Persons not walking or biking more than 10 blocks in past month
100 80 60 42 40 20 0 41 30 39

Black

Hispanic

White

Asian

Other

Persons who do not eat 5 or more servings fruits or vegetables per day
100 80 60 40 20 0 93 95 85 92 88

Black

Hispanic

White

Asian

Other

Percents are age-adjusted year year US US Standard Population and Percents are age-adjusted to theto the2000 2000 Standard Population and exclude individuals who exclud individuals who did not report age did not report age Source: NYC Community Health Survey, 2002-2004 Source: NYC Community Health Survey, 2002-2004 Source: Community Health Survey, 2003-2004 Source: NYC NYC Community Health Survey, 2003-2004 Source: NYC Community Health Survey, 2004 Source: NYC Community Health Survey, 2002,2002, 2004

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The New York City Department of Health and Mental Hygiene

Diabetes in New York City: Public Health Burden and Disparities

Chapter

MORBIDITY: HOSPITALIZATIONS
Diabetes is a common and costly cause
of hospitalization in New York City Many diabetes complications that lead to hospitalization can be prevented by effective diabetes management — including control of blood pressure, blood sugar and blood lipids through healthy eating, exercise and medication see Chapter 5 On the hospital discharge record, diabetes is sometimes listed as the principal diagnosis and other times as a listed diagnosis; in the latter instance, the principal diagnosis is often a condition in which diabetes is a contributing reason for admission for example, cardiovascular disease And sometimes, diabetes, while present, does not appear on the hospital discharge record Therefore, while hospitalization data provide a useful overview of the problem, they do not fully capture the extent of diabetes-related hospitalization In 2003, there were 20,438 hospitalizations in NYC with a principal diagnosis of diabetes –355 per 100,000 adults This rate is about the same as in 2002 — 354 per 100,000, compared to 200 per 100,000 nationwide Between 1994 and 2003, the overall diabetes hospitalization rate in NYC increased by 20, but rates were much higher in some neighborhoods New Yorkers in low-income neighborhoods
consistently experienced diabetes hospitalization rates nearly 3 times higher than those living in wealthier neighborhoods Figure 3-1 While higher diabetes prevalence in low-income communities is one reason for this disparity, other

AND

END-STAGE RENAL DISEASE
FIGURE 3-1

Diabetes hospitalization rates are increasing and are highest in low-income neighborhoods F
Hospitalizations per 100,000 adults
600 500 400 300 200 100 0 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003

Neighborhood income NYC population Low income Middle income High income

See Appendix A Rates are age-adjusted to the year 2000 US Standard Population Source: NYS DOH, Statewide Planning and Research Cooperative System SPARCS, 1994-2003; US Census, 1990 and 2000/NYC Department of City Planning

contributing factors include differences in disease severity and management Most hospitalizations with diabetes as the principal diagnosis involve complications specific for diabetes These hospitalizations are called ambulatory care sensitive because they can be prevented with effective outpatient care see Appendix A

Hospitalizations from short-term complications and uncontrolled diabetes
Short-term, potentially
life-threatening complications of poorly controlled diabetes leading to hospitalization include diabetic ketoacidosis, hyperosmolarity and coma Uncontrolled diabetes refers to blood glucose levels that put individuals with diabetes at risk for acute, potentially life-threatening complications

A goal of the US Department of Health and Human Services Healthy People 2010 is to decrease, by 2010, hospitalizations for short-term complications and uncontrolled diabetes to 54 hospitalizations per 100,000 adults 18 to 64 In 2003, the New York City hospitalization rate for short-term and uncontrolled diabetes was 116 per 100,000 adults 18 to 64 - which is more than twice as high as the Healthy People 2010 goal

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The New York City Department of Health and Mental Hygiene

Diabetes in New York City: Public Health Burden and Disparities

Chapter 3: Morbidity: Hospitalizations and End-Stage Renal Disease

Of the 20,438 hospitalizations in 2003 with a principal diagnosis of diabetes, 38 were a result of short-term complications due to uncontrolled diabetes NYC hospitalization rates for these conditions have remained fairly stable between 1994 and 2003, with 134 hospitalizations per 100,000
in 2003 Figure 3-2
FIGURE 3-2

23 Figure 3-3 Since many adults in NYC have recently-diagnosed diabetes, hospitalizations for longterm complications will continue to rise as those New Yorkers live with the condition over time

FIGURE 3-3

Hospitalizations for short-term diabetes complications due to Figure 3-2 uncontrolled diabetes have remained stable over time
Hospitalizations per 100,000 adults
250 200 150 100 50 0 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003

Hospitalizations for long-term diabetes Figure 3-3 complications have increased over time
Hospitalizations per 100,000 adults
250 200 150 100 50 0 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003

Rates are age-adjusted to the year 2000 US Standard Population Source: NYS DOH, Statewide Planning and Research Cooperative System SPARCS, 1994-2003; US Census, 1990 and 2000/NYC Department of City Planning

Rates are age-adjusted to the year 2000 US Standard Population Rates are age-adjusted to the year 2000 US Standard Population Source: NYS DOH, Statewide Planning and Research Cooperative System SPARCS, 1994-2003; Source: 1990 and Statewide Planning and Research Cooperative System SPARCS, US Census, NYS DOH,2000/NYC
Department of City Planning 1994-2003; US Census, 1990 and 2000/NYC Department of City Planning

Hospitalizations from long-term diabetes complications
Long-term diabetes complications include kidney, eye, neurological and circulatory disorders Diabetes can also lead to non-traumatic lower-extremity amputations LEA by impairing circulation, sensation and resistance to infection In 2003, of the 20,438 hospitalizations with a principal diagnosis of diabetes, 59 were a result of long-term complications Between 1994 and 2003, hospitalizations for these conditions among persons with diabetes steadily climbed from 172 per 100,000 adults in 1994 to 212 per 100,000 adults in 2003, an increase of

Non-traumatic lower-extremity amputations
A common long-term complication of diabetes is LEA, but regular foot exams and care can prevent sores and infections that lead to amputation In 2003, 75 of all LEAs occurred in adults with diabetes Between 1994 and 2000, there was a general upward trend in diabetesrelated LEA hospitalization rates, which increased by 8 to 53 per 100,000 population during this period However, rates then declined between 2000 and 2003 Since 1993, diabetes-related LEA
hospitalization rates in low-income neighborhoods have been twice those in high-income neighborhoods Figure 3-4

Another way of expressing the LEA rate is per 1,000 persons with diabetes In 2003, the LEA hospitalization rate was 4 per 1,000 persons with diabetes, a rate twice as high as the Healthy People 2010 goal of 18 per 1,000 persons with diabetes

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The New York City Department of Health and Mental Hygiene

Diabetes in New York City: Public Health Burden and Disparities

Chapter 3: Morbidity: Hospitalizations and End-Stage Renal Disease

FIGURE 3-4

F I G U R E 3 -5

Hospitalizations for lower-extremity amputation with diabetes are more frequent among residents 3-4low-income neighborhoods Figure of Figure 3-4
Hospitalizations per 100,000 adults Hospitalizations per 100,000 adults
90 90 80 80 70 70 60 60 50 50 40 40 30 30 20 20 10 10 0 0 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003

Adults with diabetes now account for more than 1 in 5 of all hospitalizations and more than 1 in 3 acute myocardial infarction MI hospitalizations
40 35 30 25 20 15 10 5 0 135 203 376

Neighborhood Neighborhood income income NYC population
NYC population Low income Low income Middle income Middle income High income High income

1994 2003
257

328 294

All Hospitalizations
See Appendix A Source: NYS DOH, Statewide Planning and Research Cooperative System SPARCS, 1994-2003; US Census, 1990 and 2000/NYC Department of City Planning

Circulatory Disorders

Acute MI

Hospitalizations with any mention of diabetes
In 2003 there were 191,366 hospitalizations among NYC adults for which diabetes was mentioned in any diagnosis field This represented 203 of all hospitalizations among adults and since 1994, a 60 increase in the number of hospitalizations with a mention of diabetes Diabetes increases the risk of heart disease and stroke, and is a listed diagnosis in nearly one-third of all hospitalizations for circulatory disorders The number of acute myocardial infarction MI hospitalizations with mention of diabetes increased 39 from 1994 to 2003, when it represented 376 of all acute MI hospitalizations Figure 3-5

Cost of diabetes hospitalizations
Between 1990 and 2003, the total cost for hospitalizations with a principal diagnosis of diabetes doubled, from 242 million in 1990 to 481 million in 2003 Figure 3-6
FIGURE 3-6

The
total cost of diabetes hospitalizations Figure in New York City has risen 3-6 dramatically since 1998
Total cost for diabetes hospitalizations millions
600 500 400 300 200 100 0

1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003

Source: NYS DOH, Statewide Planning and Research Cooperative System SPARCS, 1994-2003; US Census, 1990 and 2000/NYC Department of City Planning

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The New York City Department of Health and Mental Hygiene

Diabetes in New York City: Public Health Burden and Disparities

Chapter 3: Morbidity: Hospitalizations and End-Stage Renal Disease

This increase is due to both the rising number of hospitalizations in the past decade and the increase in average cost per hospitalization, which has risen steadily since the late 1990s Figure 3-7 In 2003, Medicare and Medicaid paid for more than three-quarters of the cost of diabetes hospitalizations in NYC Medicare was the major payor, assuming almost half of the total cost Figure 3-8

Treatment for end-stage renal disease
Renal kidney disease is a frequent long-term complication of diabetes and takes years to develop Diabetes is the leading cause of end-stage renal disease ESRD, and people with
ESRD require either dialysis or a kidney transplant Maintaining optimal control of blood sugar and blood pressure reduces the risk of developing ESRD In 2004, of the 14,113 cases of ESRD receiving dialysis or a kidney transplant, 4,865 34 were due to diabetes

FIGURE 3-7

Figure 3-9
Figure 3-5
FIGURE 3-9

The average cost per diabetes hospitalization has been Figure 3-7 increasing steadily since the late 1990s
Average cost per diabetes hospitalization in thousands
25 20 15

End-stage renal disease, New York City, End-stage renal disease,New York City, 2004 2004
Total number New patients 1 3,436
2

Number due to diabetes 1,410 4,865

Percent due to diabetes 41 34

10 5 0

Existing patients
1 2

14,113

1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003

New cases are persons first diagnosed with ESRD during 2004 Existing cases are persons living with ESRD as of 12/31/04 Source: US Renal Data System, USRDS 2006 Annual Data Report: Atlas of End-Stage Renal Disease in the United States, National Institutes of Health, National Institute of Diabetes and Digestive and Kidney Diseases, Bethesda, MD, 2006

Source: NYS DOH, Statewide Planning and Research Cooperative
System SPARCS, 1994-2003; US Census, 1990 and 2000/NYC Department of City Planning

Among newly diagnosed cases of ESRD, 41 were due
FIGURE 3-8

to diabetes, suggesting that this disease is increasingly caused by diabetes In 2004, the total Medicare costs of ESRD due to diabetes reached almost 82 billion nationally, up from 47 billion in 1998 In New York State alone, Medicare costs of ESRD were 527 million in 2004, US Renal Data System, 2006

Medicare and Medicaid paid more than three-quarters of diabetes hospitalization charges in 2003
16
Health insurance type Private Insurance Medicare Medicaid Other Self-pay/Uninsured

Figure 3-8

4 1 47

Rates are age-adjusted to the the year 2000 US Standard Population Percents are age-adjusted to year 2000 US Standard Population Source: NYS DOH, Statewide Planning and Research Cooperative System SPARCS, 1994-2003; Source: NYS DOH, Statewide Planning and Research Cooperative System SPARCS, 1994-2003; US Census,2000/NYC Department of City Planning City Planning US Census, 1990 and 1990 and 2000/NYC Department of

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The New York City Department of Health and Mental Hygiene

Diabetes in New York City: Public Health Burden and
Disparities

Chapter

MORTALITY
In 2003, diabetes was listed as the underlying cause of 1,819 New York City deaths This reflects an ageadjusted mortality rate of 24 per 100,000 population, making diabetes the 4th leading cause of death among New Yorkers, up from 6th in 2002 More than half 952 of these diabetes deaths occurred before age 75 On average, each of these deaths resulted in 14 years of potential life lost before age 75 YPLL75 Among New Yorkers, blacks had the highest rate of mortality 42 per 100,000 population and YPLL75 The number of deaths that list diabetes as the underlying cause greatly underestimates the overall impact of this disease on mortality Diabetes also increases the risk of death from other conditions, including cardiovascular disease the most common cause of death among people with diabetes, kidney disease and pneumonia
FIGURE 4-1

288 years per 100,000 from diabetes–28 and 23 times higher, respectively, than the rates among whites Figure 4-1

The death rate from diabetes among blacks is nearly three times that of whites
Number of deaths1 All New Yorkers Black Hispanic White Asian 1,819 653 400 583 90 Deaths before age 75 952 366 250 235 57
Age-adjusted death rate/100,000 population 24 42 32 15 17 Average YPLL per death before age 75 14 15 14 14 11 YPLL/100,000 population 75 years of age 174 288 160 127 84

1 The sum of deaths by race/ethnicity will not equal the total number of deaths because residents with unknown or other race/ethnicity are not shown Rates are age-adjusted to the year 2000 US Standard Population Source: Bureau of Vital Statistics, NYC DOHMH, 2003; US Census 2000/NYC Department of City Planning

FIGURE 4-2

Diabetes is a contributing cause of thousands of deaths each year, most from cardiovascular disease
Underlying cause on death certificate Total number of deaths1 Number of deaths with diabetes as contributing cause 2 1,631 309 125 145 94 33 28 50 69 55 2,943 Percent of death certificates with any mention of diabetes as contributing cause 7 3 5 8 6 2 3 7 13 18 5

Cardiovascular disease Cancer Influenza and pneumonia Cerebrovascular disease Chronic lower respiratory disease Human immunodeficiency virus HIV Accidents except drug poisoning Nephritis, nephritic syndrome and nephrosis includes renal failure Septicemia Essential hypertension and renal diseases All deaths
1

23,320 12,167 2,279 1,741
1,616 1,602 950 677 535 305 55,448

Total deaths by underlying cause as coded by NCHS differ from totals as coded by NYC Bureau of Vital Statistics and reported in 2002 Annual Summary 2 The number of deaths from NCHS Multiple-Cause File excludes decedents with unknown residence in the NYC Vital Statistics mortality file Source: NCHS Multiple-Cause Mortality File, 2002/analyzed by Bureau of Vital Statistics, NYC DOHMH

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The New York City Department of Health and Mental Hygiene

Diabetes in New York City: Public Health Burden and Disparities

Chapter 4: Mortality

In such cases, diabetes may be listed as a contributing cause In 2002, the most recent multiple-cause data available for NYC, diabetes was the underlying cause for 1,625 deaths and listed as a contributing cause on an additional 2,943 death certificates NCHS, 2002 Figure 4-2 Thus measured, diabetes caused or contributed to 8 of NYC deaths in 2002 This is likely to be an underestimate, as
100

FIGURE 4-3
Figure 4-3 Diabetes mortality rates increase sharply at older ages

Diabetes mortality rate per 100,000 population, all ages
200

Male Female

150

diabetes is underreported as an underlying or contributing cause of
death nationwide Among persons who die with diabetes, it is estimated that only 10 to 15 of death certificates list it as an underlying cause, and on 35 to 40 is it listed anywhere on the death certificate CDC, National Diabetes Fact Sheet, 2003
FIGURE 4-4
50

0 17 18-24 25-44 45-64 65

Age group years
Source: Bureau of Vital Statistics, NYC DOHMH, 2003; US Census 2000/NYC Department of City Planning

Diabetes mortality rates increase sharply with age in both men and women In 2003, the mortality rates among men and women aged 65 years and older were 5 and 8 times higher, respectively, than among those aged 45 to 64 years Figure 4-3 In NYC, diabetes mortality rates increased by 71 between 1990 and 2003, from 14 to 24 per 100,000 population Historically, mortality rates have been lower in New York City than nationwide However, since 1994 mortality rates in the city have been approaching national rates, and in 2003 the city and US rates were virtually identical Figure 4-4

Mortality rates due to diabetes have increased since 1990
Diabetes mortality rate per 100,000 population, all ages
30 25 20 US 15 10 5 0
1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002
2003

NYC

Rates are age-adjusted to the year 2000 US Standard Population Sources: Bureau of Vital Statistics, NYC DOHMH, 1990-2003; US Census 2000/NYC Department of City Planning; CDC/NCHS, National Vital Statistics System, 1990-2003

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The New York City Department of Health and Mental Hygiene

Diabetes in New York City: Public Health Burden and Disparities

Chapter 4: Mortality

Diabetes mortality rates have increased over time among all racial/ethnic groups, but blacks and Hispanics have been disproportionately affected For example, compared with white adults, the diabetes mortality rate among Hispanic adults was 14 times greater in 1990 but 25 times greater in 2003 While black New Yorkers have consistently had the highest diabetes mortality rates, Hispanics have experienced the greatest increase in mortality 169 since 1990 Figure 4-5 Between 1990 and 2003, diabetes mortality rates have increased in all NYC neighborhoods However, mortality rates in low-income neighborhoods have been consistently 2 times higher than rates in high-income neighborhoods Figure 4-6

FIGURE 4-5

Mortality rates from Figure 4-5 increasing in all diabetes are racial/ethnic groups, though most rapidly
in Hispanics
Diabetes mortality rate per 100,000 population, all ages
50

Black
40 30 20 10 0

Hispanic White Asian

1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003

Rates are age-adjusted to the year 2000 US Standard Population Sources: Bureau of Vital Statistics, NYC DOHMH, 1990-2003; US Census 2000/NYC Department of City Planning

FIGURE 4-6

Neighborhood disparities in diabetes mortality rates persist over time, Figure 4-6 with low-income neighborhoods experiencing the highest rates
Diabetes mortality rate per 100,000 population, all ages
50 45 40 35 30 25 20 15 10 5 0

Neighborhood income Low Middle High

1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003

See Appendix A Rates are age-adjusted to the year 2000 US Standard Population Source: Bureau of Vital Statistics, NYC DOHMH, 1990-2003; US Census 2000/NYC Department of City Planning

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The New York City Department of Health and Mental Hygiene

Diabetes in New York City: Public Health Burden and Disparities

Chapter

HEALTH CARE INDICATORS
The risk of diabetes-related complications and mortality can be reduced with effective medical care This chapter summarizes available data on
access to health care for New Yorkers with diabetes and receipt of care that can reduce diabetes complications
FIGURE 5-1

Having health insurance, a regular primary care provider and a usual source of care are important components of health care access Among adults 18 and older with diabetes, the vast majority have health insurance and a primary care provider Figure 5-1 More than 4 in 10 reported being covered by Medicaid or Medicare Figure 5-2 Still, an estimated 35,000 adults with diabetes do not have insurance, and 62,000 do not have a primary care provider

The majority of adults with diabetes have Figure 5-1 health care coverage and a primary care provider
Adults with diabetes
100 90 80 70 60 50 40 30 20 10 0 Have health insurance Have primary care provider 89 83

Obtaining routine medical care from an emergency department can indicate poor access to primary care and can lead to poor continuity of care Among New Yorkers with diabetes, those with the lowest household incomes are 12 times more likely to use an emergency department as their usual source of care than those with high incomes Figure 5-3
FIGURE 5-3

Percents are age-adjusted to the year 2000 US Standard Population
and exclude individuals who did not report age Source: NYC Community Health Survey, 2002-2004

FIGURE 5-2

More than 4 in 10 adults with diabetes in New York City have public insurance
6 11 39
Health insurance type Private Medicaid/Medicare No insurance Other

Figure 5-2

Adults with diabetes with the lowest incomes are most likely Figure 5-3 to use emergency departments as their usual place of care
Adults with diabetes who use emergency departments as usual source of care
14 12 12 10 8 6 4 2 4

1 200 200-599 600

Household income of federal poverty level
Percents are age-adjusted to the year 2000 US Standard Population and exclude individuals who did not report age Source: NYC Community Health Survey, 2002-2004 Estimate has a relative standard error 30 and should be interpreted with caution Percents are age-adjusted to the year 2000 US Standard Population and exclude individuals who did not report age Source: NYC Community Health Survey, 2003-2004

5-1

The New York City Department of Health and Mental Hygiene

Diabetes in New York City: Public Health Burden and Disparities

Chapter 5: Health Care Indicators

The majority of adults with diabetes had a checkup in the past
year and received counseling on weight, nutrition or exercise at their last doctors visit However, only 44 have ever taken a diabetes self-management class Figure 5-4
FIGURE 5-4
Figure 5-4 While most adults with diabetes had a routine checkup in the past year, fewer than half have taken a diabetes self-management class
Adults with diabetes
100 80 60 44 40 20 0 Had routine checkup in past 12 months Received counseling on weight, nutrition, or exercise at last doctors visit Took diabetes management class 88 74

for persons with diabetes Four in 5 adults with diabetes in New York City report having had at least 1 hemoglobin A1C test in the past year, but only 16 of those reporting a test know their A1C level Eye and foot examinations are also an important component of care, since those
FIGURE 5-5

Four in 5 adults with diabetes had at least 1 hemoglobin A1C Figure 5-5 test in the past year, but more than 1 in 3 adults did not receive an eye or foot exam
Adults with diabetes
100
81

80
63 62

60 40 20 0 Had one or more hemoglobin A1C tests in past year Had eye exam in past year Had one or more foot exams in past year

Percents are age-adjusted to the year 2000 US Standard Population
and exclude individuals who did not report age Source: NYC Community Health Survey, 2004

Percents are age-adjusted to the year 2000 US Standard Population and exclude individuals who did not report age Source: NYC Community Health Survey, 2002 Source: NYC Community Health Survey, Spring, Fall 2003

While good diabetes management involves many lifestyle changes and health care measures, the most important actions are described as the ABCs: controlling blood sugar defined as an A1C 7, keeping Blood pressure below 130/80, keeping the level of LDL or bad Cholesterol below 100, and quitting or abstaining from Smoking Improving control of blood glucose levels reduces the risk of diabetes complications affecting the heart, eyes, kidneys and nerves A hemoglobin A1C test reflects the average amount of glucose in the blood over the past 2 to 3 months and is recommended at least twice a year

with diabetes are vulnerable to a variety of serious complications such as glaucoma, cataracts, retinopathy and lower-extremity amputations While many New Yorkers with diabetes had an eye exam and at least 1 foot exam in the past year, more than 1 in 3 did not receive these exams Figure 5-5 For people
with diabetes, control of high blood pressure and cholesterol levels to prevent cardiovascular disease is especially important The great majority of adults with diabetes have had their blood pressure and cholesterol level checked in the past year, but available data suggest

Starting in January 2006, NYC DOHMH has mandated electronic laboratory reporting of hemoglobin A1C values to permit surveillance on the extent to which A1C levels are under adequate control see wwwnycgov/health/diabetes

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The New York City Department of Health and Mental Hygiene

Diabetes in New York City: Public Health Burden and Disparities

Chapter 5: Health Care Indicators

most do not have these risk factors well controlled see page 5-4 Another strategy for preventing heart attacks among adults with diabetes is regular use of aspirin Fewer than 1 in 4 New Yorkers with diabetes reports taking aspirin daily or every other day Figure 5-6

Although people with diabetes are at increased risk of complications or death from influenza and pneumonia, only 43 of adults with diabetes report having had a flu shot in the past year Even fewer had ever received a pneumonia shot 28 Figure 5-7 Data for a subset of
low-income NYC adults with diabetes those enrolled in Medicaid1 indicate that the vast majority received hemoglobin A1C tests in the past year However, only 57 of those tested had a recent level of 9, meaning that 43 had very poor control of blood glucose levels Similarly, while 88 of those with diabetes had a cholesterol test in the past 2 years, only 34 had an LDL low-density lipoprotein, or bad

FIGURE 5-6

Most New Yorkers with diabetes had their blood pressure Figure 5-6 and cholesterol checked in the past year, but fewer than 1 in 4 takes aspirin regularly
Adults with diabetes
100 80 60 40 23 20 0
Blood pressure checked in past year Cholesterol test in past year Aspirin taken daily or every other day

cholesterol level less than 100 the goal set in national guidelines for those with diabetes NHLBI, 2001 Other diabetes care was not delivered consistently: 58 had an eye exam in the past 2 years and 49 were screened for kidney damage Figure 5-8

Percents are age-adjusted to the year 2000 US Standard Population and exclude individuals who did not report age Source: NYC Community Health Survey, 2002

FIGURE 5-7
Figure 5-8

FIGURE 5-8

Fewer than half of adults with
diabetes had a flu shot in the Figure ever past year, and only 1 in 4 has5-7 had a pneumonia shot
Adult with diabetes
100 80 60 43 40 28 20 0
Had a flu shot in past year Ever had a pneumonia shot

Among Medicaid enrollees with diabetes, care is variable
Adults with diabetes enrolled in Medicaid managed care plan
100 83 80 60 40 20 0 Hemoglobin A1C test in past year Most recent hemoglobin A1C test indicated level of 9 Cholesterol test in past 2 years Most recent Most recent level of LDL level of LDL 130 mg/dL was controlled LDL-C100 mg/dL Eye exam in past 2 years Screened for kidney damage 57 58 58 49 34 88

Percents are age-adjusted to the year 2000 US Standard Population and exclude individuals who did not report age Source: NYC Community Health Survey, 2002-2004

QARR performance measures
Among persons who had a cholesterol test in past 2 years Source: NYS DOH, Quality Assurance Reporting Requirements QARR, 2004

New York State Department of Healths Quality Assurance Reporting Requirements QARR consist of a set of clinical and administrative performance indicators reported by managed care plans For New York City adults with diabetes enrolled in Medicaid, QARR provides a way
to assess the quality of care and the extent to which diabetes is well managed

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The New York City Department of Health and Mental Hygiene

Diabetes in New York City: Public Health Burden and Disparities

Chapter 5: Health Care Indicators

Among people with diabetes who were enrolled in Medicare2 from April 2001 to March 2003, 79 had their hemoglobin A1C checked at least once, 73 had one or more eye exams, and 88 had their cholesterol level checked at least once, based on claims submitted Figure 5-9 Until recently, no systematic data on diabetes control were available for all NYC adults with the condition Data from the 2004 NYC HANES show that most adults with diagnosed diabetes are not meeting goals for A1C, blood pressure or cholesterol ABCs, and that 1 in 4 is a current smoker Figure 5-10 For those with undiagnosed diabetes, the proportion not meeting goals for A1C, blood pressure or cholesterol is somewhat lower probably because their diabetes developed more recently and is less severe

Cigarette smoking increases the risk of developing both diabetes and diabetes-related complications, including cardiovascular disease, lower-extremity amputations, nerve damage and kidney
disease An estimated 1 in 3 adults with undiagnosed diabetes is a current smoker Based on data from the Community Health Survey, among adults with diabetes who smoke, only 38 tried to quit using an effective cessation aid like nicotine patches, prescription medication or counseling Health care providers can play a key role in reducing the impact of smoking by assessing smoking status at every visit, advising patients to quit and recommending or prescribing the use of medications and other effective cessation aids

FIGURE 5-9

F I G U R E 5-10

Among Medicare enrollees with diabetes, most had Figure 5-9 a hemoglobin A1C test, eye exam, and lipid profile
Adults with diabetes , age 65
100 90 80 70 60 50 40 30 20 10 0 One or more hemoglobin A1C tests One or more eye exams One or more lipid profiles 0 10 30 20 40 79 73 50 88 60 70

Most New Yorkers with diabetes are not meeting goals for control of ABCs
of adults with diabetes
65 55 50 50 38 63

Diagnosed Diabetes Undiagnosed Diabetes

30 22

A1C 7

Elevated blood pressure 130/80

LDL 100

Current smoker

Among adults enrolled in Medicare from October 1, 2002-September 30, 2004 Percents are not age-adjusted Source: IPRO,
2002-2004

Source: NYC Health and Nutrition Examination Survey

The Medicare-eligible population includes those eligible because they are 65 or older or are disabled

5-4

The New York City Department of Health and Mental Hygiene

Diabetes in New York City: Public Health Burden and Disparities

Chapter

DIABETES DURING PREGNANCY
Metabolic changes during pregnancy can cause diabetes in women who did not have it before pregnancy; this is called gestational diabetes Gestational diabetes and diabetes present before pregnancy are associated with macrosomia large-for-gestational-age babies, complications of labor and delivery, cesarean delivery, stillbirth, pre-term birth, congenital malformations and infant mortality Preconception counseling for those with chronic diabetes and timely screening for pregnant women are essential to identify and treat diabetes during pregnancy Birth records use a check box system to capture maternal diabetes This chapter summarizes demographic patterns of diabetes during pregnancy, including chronic and gestational, as noted on birth records
Singleton births only Among women of all ages Source: Bureau of Vital Statistics, NYC DOHMH,
1990-2003/analyzed by Health Promotion and Disease Prevention, Research, Surveillance, Evaluation, NYC DOHMH 1

has increased in both age groups since 1990, women 34 and younger experienced a 46 increase, compared with a 20 increase among older women Figure 6-2
FIGURE 6-1

The rate of diabetes during pregnancy has increased over time Figure 6-1
Rate per 1,000 live births
45 40 35 30 25 20 15 10 5 0

Type of diabetes during pregnancy Any diabetes Gestational diabetes diagnosed during pregnancy Chronic diabetes diagnosed before pregnancy

1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003

The rate of any diabetes during pregnancy among
FIGURE 6-2

delivering mothers increased 47 between 1990 and 2003 Among mothers identified with diabetes on birth certificates, gestational diabetes is far more common than chronic diabetes In 2003, rates of gestational and chronic diabetes were 39 and 4 per 1,000 live births, respectively Figure 6-1 The risk of any diabetes during pregnancy increases with maternal age Between 1990 and 2003, the prevalence of diabetes during pregnancy was markedly higher among women 35 and older than among younger women However, while the rate of
diabetes during pregnancy
Rates of diabetes during pregnancy have remained consistently Figure higher among older 6-2 mothers over time
Rate per 1,000 live births
90 80 70 60 50 40 30 20 10 0

Mothers age 35 years old 35 years old

1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003

Singleton births only Among women of all ages Source: Bureau of Vital Statistics, NYC DOHMH, 1990-2003/analyzed by Health Promotion and Disease Prevention, Research, Surveillance and Evaluation Unit, NYC DOHMH

Because gestational diabetes is a risk factor for developing chronic diabetes, or may be the first indication of chronic diabetes, follow-up clinical evaluation for diabetes after pregnancy is essential for all those diagnosed with gestational diabetes

A first-time diagnosis of diabetes during pregnancy can indicate onset of diabetes resulting from the pregnancy, or detection of pre-existing diabetes Thus, when diabetes is first diagnosed during pregnancy, it may not be known whether it was present prior to the pregnancy A new diagnosis of diabetes during pregnancy is recorded on birth records as gestational diabetes despite this uncertainty Diabetes is recorded as chronic
if it was diagnosed prior to pregnancy

6-1

The New York City Department of Health and Mental Hygiene

Diabetes in New York City: Public Health Burden and Disparities

Chapter 6: Diabetes During Pregnancy

Between 1990 and 2003, the rate of any diabetes during pregnancy increased in all racial/ethnic groups, and disparities between groups widened Rates of diabetes during pregnancy were highest and increased dramatically by 57 among Asian women to 72 per 1,000 live births in 2003 Rates were lower among black women but rose most rapidly in this group by 63 Figure 6-3
FIGURE 6-3

direct relationship to diabetes Compared to women reporting a pre-pregnancy weight of 100 to 149 pounds, the prevalence of diabetes during pregnancy is nearly twice as high among women reporting pre-pregnancy weights of 150 to 199 pounds and nearly five times greater 15 of pregnancies for mothers weighing more than 300 pounds Figure 6-5
FIGURE 6-4
Figure during pregnancy among Asian The high prevalence of diabetes 6-4 mothers is due to the high rate seen among South and Central Asians
Rate per 1,000 live births
140 122

Rates of diabetes during pregnancy have been highest Figure 6-3 and have increased the
most among Asian mothers
Rate per 1,000 live births
90 80 70 60 50 40 30 20 10 0

Race/Ethnicity Black Hispanic White Asian

120 100 80 60 41 40 20 0 43 26 49

1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003

Black

Hispanic

White

South and Central Asian

Other Asian

Singleton births only Among women of all ages Source: Bureau of Vital Statistics, NYC DOHMH, 2003/analyzed by Health Promotion and Disease Prevention, Research, Surveillance and Evaluation Unit, NYC DOHMH

FIGURE 6-5

The high prevalence of diabetes during pregnancy among Asian mothers is most striking among South and Central Asians, with a rate of 122 per 1,000 live births This represents 1 in 8 live births, a rate 25 times the rate in other Asian mothers, and more than 45 times the rate in white mothers Figure 6-4 As with chronic diabetes, overweight and obesity increase the risk of diabetes during pregnancy Although body mass index BMI during pregnancy cannot be determined from New
York City birth certificates, pre-pregnancy weight recorded on birth certificates shows a strong,
There is a direct association between diabetes during Figure 6-5 pregnancy and maternal pre-pregnancy weight
Maternal diabetes per 1,000 live births
160 140 120 100 80 60 40 22 20 0 Less than 99 lbs 100-149 lbs 150-199 lbs 200-299 lbs 300 lbs Unknown 31 57 40 99 151

Pre-pregnancy weight
Singleton births only Among women of all ages Source: Bureau of Vital Statistics, NYC DOHMH, 2003/analyzed by Health Promotion and Disease Prevention, Research, Surveillance and Evaluation Unit, NYC DOHMH

6-2

The New York City Department of Health and Mental Hygiene

Diabetes in New York City: Public Health Burden and Disparities

Chapter 6: Diabetes During Pregnancy

Half of women with diabetes during pregnancy reported a pre-pregnancy weight of 150 pounds or more, which would be overweight BMI25 for a woman of average height 5 feet, 4 inches Figure 6-6
FIGURE 6-6

Half of women with diabetes during pregnancy had Figure 150 a pre-pregnancy weight of6-6 pounds or more
300 lbs 1 200-299 lbs 15 100-149 lbs 46 Unknown 2

100 lbs 1

150-199 lbs 36

Pre-pregnancy weight
Singleton births only Among women
of all ages Source: Bureau of Vital Statistics, NYC DOHMH, 2003/analyzed by Health Promotion and Disease Prevention, Research, Surveillance and Evaluation Unit, NYC DOHMH

6-3

The New York City Department of Health and Mental Hygiene

Diabetes in New York City: Public Health Burden and Disparities

appendix

ABOUT THE DATA
Adult prevalence, health care indicators, risk factor data
The New York City Community Health Survey CHS is a telephone survey conducted among non-institutionalized adults aged 18 and older The survey is based on the CDC Behavioral Risk Factor Surveillance System BRFSS; CDC, 2005 The CHS used a stratified random sample of United Hospital Fund UHF neighborhoods in the city Households were selected at random using a random digit dialing method Interviews were conducted in many languages, including Spanish Additionally, SPARCS data on the race and ethnicity of individual patients are imprecise These data are not collected in a standardized manner across hospitals, and large numbers of records have race listed as other Consequently, race/ethnicity-specific rates for diabetes hospitalization could not be calculated We used SPARCS data to estimate ambulatory
caresensitive hospitalizations AHRQ, 2001 which were identified and classified using the following ICD-9 codes: Short-term diabetes complications and uncontrolled diabetes 25010, 25011, 25012, 25013, 25020, 25021, 25022, 25023, 25030, 25031, 25032, 25033 Long-term diabetes complications 25040, 25041, 25042, 25043, 25050, 25051, 25052, 25053, 25060, 25061, 25062, 25063, 25070, 25071, 25072, 25073, 25080, 25081, 25082, 25083, 25090, 25091, 25092, 25093 Hospital discharges that listed diabetes as a diagnosis were used to examine discharges involving lower extremity amputations LEA indicated by procedure code 8410, 8411, 8412, 8413, 8414, 8415, 8416, 8417, 8418, 8419 Discharges with a traumatic amputation diagnosis code ICD-9 codes 8950, 8951, 8960, 8961, 8962, 8963, 8970, 8971, 8972, 8973, 8974, 8975, 8976, 8977 were excluded
APXA-1
The New York City Department of Health and Mental Hygiene

Interpretation and presentation of the SPARCS data present certain difficulties The data represent numbers of hospitalizations, not numbers of individuals hospitalized Since some persons with diabetes may be hospitalized repeatedly in any given year, the numbers or rates may overestimate the number
of persons with diabetes hospitalized

New York City Health and Nutrition Examination Survey NYC HANES
NYC HANES was a household-based examination survey conducted among non-institutionalized NYC adults aged 20 and older The survey is based on the National Health and Nutrition Examination Survey NHANES NYC HANES used a 3-stage cluster sample to achieve a representative sample of NYC adults Households and participants were randomly selected from 144 city neighborhoods Those individuals comprising the sample participated in a health interview and brief examination Interviews were conducted in English and Spanish; interpreters were used for other languages

Hospitalization data
The Statewide Planning and Research Cooperative System SPARCS; New York State Department of Health, 2006 data set consists of hospital discharge administrative records for acute care hospitals in New York State Criteria for inclusion of SPARCS records in this fact book included 1 a diagnosis code for diabetes AHRQ, 2005 and 2 residence in NYC as determined by zip code at the time of the hospitalization

Diabetes in New York City: Public Health Burden and Disparities

Appendix A: About The Data

The LEA
hospitalization rate per 1,000 persons with diabetes in 2003 was calculated using an estimate of the population with diabetes from the NYC Community Health Survey

NYC HANES were obtained from the 2004 American Community Survey and Current Population Survey, conducted by the Census Bureau

Medicaid data Treatment of end-stage renal disease ESRD
The United States Renal Data System USRDS is a data system that collects and distributes national data on end-stage renal disease ESRDThe data reported here have been supplied by USRDS The interpretation and reporting of these data are the responsibility of the authors and in no way should be seen as an official policy or interpretation of the US government New York State Department of Healths Quality Assurance Reporting Requirements QARR provided data on health care indicators among Medicaid enrollees QARR consist of a set of clinical and administrative performance indicators reported by managed care plans For NYC adults with diabetes who are enrolled in Medicaid, QARR provides a way to assess the quality of care and the extent to which diabetes is well managed

Mortality data
Mortality data are based on deaths of NYC residents whose
underlying cause of death was diabetes This categorization is selected in accordance with rules issued by the National Center for Health Statistics NCHS and codes of the International Classification of Diseases, Tenth Revision ICD10 Demographic data on death certificates are coded in agreement with NCHS standards Interpretation of mortality data can be complicated because deaths with diabetes listed as underlying cause greatly underestimate the overall impact of diabetes on mortality Studies have found that only 35 to 40 of persons who die with diabetes have it listed anywhere on the death certificate CDC, National Diabetes Fact Sheet, 2003

Medicare data
Data on health care indicators among Medicare enrollees were compiled from summary claims data analyzed and provided to NYC DOHMH by IPRO, Lake Success, New York

Comparison data
National diabetes and obesity prevalence data were based on the National Health Interview Survey 2004 Lethbridge-Cejku et al, 2006

Presentation of data
Rates with relative standard errors RSEs of 30 indicated low reliability These rates are either not presented or footnoted in the charts and/or tables These rates should be interpreted with caution In
this report, neighborhoods are groups of zip codes defined by the United Hospital Fund UHF Neighborhood income is defined by the percent of households in the neighborhood below 200 of the federal poverty guidelines and separated into thirds: low-income 45-90, middle-income 30-44 and high-income 30
The New York City Department of Health and Mental Hygiene

Census data
Population counts used as denominators for rates and to compute weights for the Community Health Survey are based on the year 2000 Census Because of population growth since 2000, hospitalization and mortality rates may be overestimated, especially in neighborhoods where the population has increased significantly in recent years Population estimates used to compute weights for the
APXA-2

Diabetes in New York City: Public Health Burden and Disparities

appendix

NEIGHBORHOOD TABLES

AND

MAPS

Diabetes prevalence by UHF neighborhood: age-adjusted percentage, ages 18, New York City, 2002-2004

Prevalence
17 - 31 32 - 69 70 - 96 97 - 129 130 - 169
301 106 107 302 303 304 305 306 307 401 404 402 406 308 309 310 211 202 203 204 407 201 405 408 409 403 101 102 103

105 104

205 207 501 206 208 502 503 210 209 410

504

Percents are age adjusted to the year 2000 US Standard Population

APXB-1

The New York City Department of Health and Mental Hygiene

Diabetes in New York City: Public Health Burden and Disparities

Appendix B: Neighborhood Tables and Maps

Diabetes prevalence by borough and UHF neighborhood: number and age-adjusted percentage, ages 18, New York City, 2002-2004
Age-adjusted percent

UHF

Neighborhood

Estimated number

101 102 103 104 105 106 107 201 202 203 204 205 206 207 208 209 210 211 301 302 303 304 305 306 307 308 309 310 401 402 403 404 405 406 407 408 409 410 501 502 503 504

Bronx Kingsbridge-Riverdale Northeast Bronx Fordham-Bronx Park Pelham Crotona-Tremont Highbridge-Morrisania Hunts Point-Mott Haven Brooklyn Greenpoint Downtown-Heights-Slope Bedford Stuyvesant-Crown Heights East New York Sunset Park Borough Park East Flatbush -Flatbush Canarsie-Flatlands Bensonhurst-Bay Ridge Coney Island-Sheepshead Bay Williamsburg-Bushwick Manhattan Washington Heights-Inwood Central Harlem-Morningside Heights East Harlem Upper West Side Upper East Side Chelsea-Clinton Gramercy Park-Murray Hill Greenwich Village-SoHo Union Square-Lower East Side Lower Manhattan Queens Long Island
City-Astoria West Queens Flushing-Clearview Bayside-Little Neck Ridgewood-Forest Hills Fresh Meadows Southwest Queens Jamaica South East Queens Rockaway Staten Island Port Richmond Stapleton-St George Willowbrook South Beach-Tottenville

102,000 5,000 17,000 18,000 23,000 12,000 16,000 11,000 164,000 6,000 8,000 24,000 15,000 7,000 19,000 22,000 13,000 12,000 24,000 15,000 76,000 19,000 12,000 9,000 9,000 6,000 5,000 2,000 3,000 9,000 1,000 140,000 12,000 26,000 13,000 5,000 14,000 6,000 18,000 22,000 17,000 7,000 23,000 4,000 6,000 6,000 7,000

121 61 119 124 111 114 165 169 97 77 58 123 157 91 83 105 89 73 95 145 66 105 120 129 50 31 57 17 49 64 55 85 78 82 59 61 69 77 96 111 108 94 71 90 77 91 51

Source: NYC Community Health Survey, 2002-2004 Percents are age adjusted to the year 2000 US Standard Population Prevalence has a relative standard error 30 and should be interpreted with caution

APXB-2

The New York City Department of Health and Mental Hygiene

Diabetes in New York City: Public Health Burden and Disparities

Appendix B: Neighborhood Tables and Maps

Diabetes hospitalizations by UHF neighborhood: age-adjusted rate, adults ages 18, New York City,
2003

Hospitalizations per 100,000
884 - 1884
101

1885 - 2822 2823 - 4677 4678 - 7044 7045 - 9369
302 303 304 305 306 401 307 402 308 309 310 201 211 202 203 205 501 206 502 503 209 210 207 208 204 405 301 106 107 103 105

102

104

403 404 406

408 407 409

410

504

Rates are calculated using US Census 2000 and age-standardized to the year 2000 US Standard Population

APXB-3

The New York City Department of Health and Mental Hygiene

Diabetes in New York City: Public Health Burden and Disparities

Appendix B: Neighborhood Tables and Maps

Diabetes hospitalizations by borough and UHF neighborhood: number of hospitalizations and age-adjusted rate, adults ages 18, New York City, 1994 and 2003
UHF Neighborhood
1994 Age-adjusted rate/100,000 2003 Age-adjusted rate/100,000 change

Number

101 102 103 104 105 106 107 201 202 203 204 205 206 207 208 209 210 211 301 302 303 304 305 306 307 308 309 310 401 402 403 404 405 406 407 408 409 410 501 502 503 504

Bronx Kingsbridge Northeast Bronx Fordham-Bronx Park Pelham-Throgs Neck Crotona-Tremont Highbridge-Morrisania Hunts Point-Mott Haven Brooklyn Greenpoint Downtown-Heights-Slope Bedford Stuyvesant Crown Heights East New York
Sunset Park Borough Park East Flatbush-Flatbush Canarsie-Flatlands Bensonhurst-Bay Ridge Coney Island Williamsburg-Bushwick Manhattan Washington Heights-Inwood Central Harlem East Harlem Upper West Side Upper East Side Chelsea-Clinton Gramercy Park-Murray Hill Greenwich Village-SoHo Union Square-Lower East Side Lower Manhattan Queens Long Island City-Astoria West Queens Flushing-Clearview Bayside-Little Neck Ridgewood-Forest Hills Fresh Meadows Southwest Queens Jamaica Southeast Queens Rockaway Staten Island Port Richmond Stapleton-St George Willowbrook South Beach-Tottenville

3244 172 416 514 625 529 592 394 5847 249 508 1105 504 222 481 696 380 329 602 764 3093 595 551 507 328 142 217 153 102 443 44 3541 332 563 301 93 351 123 351 737 361 277 768 160 289 115 204

391 214 292 353 309 555 632 622 352 330 359 560 551 324 211 347 269 197 240 705 263 338 527 723 181 77 211 137 158 292 210 221 214 191 145 120 175 169 199 381 243 351 270 431 370 200 186

4870 262 618 759 849 894 930 558 6962 214 523 1390 628 272 519 937 501 306 644 1021 3424 748 630 649 316 166 188 158 64 432 65 4242 335 702 373 102 374 120 471 930 500 331 940 154 319 175 292

566 329 424 516 406 863 914 837 404 282
375 704 652 378 216 468 345 178 253 937 290 420 607 896 175 88 188 142 103 282 271 254 216 223 169 126 184 155 258 459 325 419 290 378 372 262 223

45 54 45 46 32 56 45 35 15 -14 5 26 18 16 3 35 28 -10 6 33 10 24 15 24 -3 15 -11 3 -35 -4 29 15 1 17 16 5 5 -8 30 20 34 20 7 -12 1 31 19

Source: NYS DOH, Statewide Planning and Research Cooperative System, 1994-2003 updated April 2004; Rates are calculated using US Census 1990, 2000 and age-standardized to the year 2000 US Standard Population

APXB-4

The New York City Department of Health and Mental Hygiene

Diabetes in New York City: Public Health Burden and Disparities

Appendix B: Neighborhood Tables and Maps

Lower-extremity amputation LEA with diabetes hospitalizations by UHF neighborhood: age-adjusted rate, adults ages 18, New York City, 2003

Hospitalizations per 100,000
115 - 230 231 - 429 430 - 580 581 - 931 932 - 1538
302 303 304 305 306 401 307 402 308 309 310 201 211 202 203 204 205 501 206 502 503 209 210 207 208 410 407 405 408 409 406 403 404 301 106 107 103 105 104 101 102

504

Rates are calculated using US Census 2000 and age-standardized to the year 2000 US Standard Population Fewer than 6 cases Rate not
computed

APXB-5

The New York City Department of Health and Mental Hygiene

Diabetes in New York City: Public Health Burden and Disparities

Appendix B: Neighborhood Tables and Maps

Lower-extremity amputation LEA with diabetes hospitalizations by borough and UHF neighborhood: number of hospitalizations and age-adjusted rate per 100,000 adults ages 18, New York City, 1994 and 2003
UHF Neighborhood
Number 1994 Age-adjusted rate/100,000 Number 2003 Age-adjusted rate/100,000 change

101 102 103 104 105 106 107 201 202 203 204 205 206 207 208 209 210 211 301 302 303 304 305 306 307 308 309 310 401 402 403 404 405 406 407 408 409 410 501 502 503 504

590 37 109 95 146 69 83 51 828 27 74 149 64 18 90 88 59 47 109 103

737 429 744 697 725 806 999 859 508 379 581 810 815 275 383 492 410 299 409 1046 439 571 623 1159 447 161 458 196 197 441 324
388 292 303 329 232 422 252 347 614 303 835 462 607 464 535 367

721 63 118 126 154 95 102 74 907 29 75 166 85 46 72 130 58 48 90 108 510 129 74 108 64 22 30 13 12 55 695 48 122 76 29 60 18 72 134 72 63 125 23 36 25 41

879 694 787 931 743 1034 1124 1177 536 384 574 895 983 682 305 691 400 273 331 1064 447 768 738 1538 367 115 310 123 189 368 420 329 401 335 339 294 230 398 672 470 796 385 580 429 364 309

19 62 6 34 2 28 13 37 6 1 -1 10 21 148 -20 40 -2 -9 -19 2 2 35 18 33 -18 -29 -32 -37 -4 -17 8 13 32 2 46 -30 -9 15 9 55 -5 -17 -4 -8 -32 -16

Manhattan 500 Washington Heights-Inwood 97 Central Harlem 65 East Harlem 78 Upper West Side 78 Upper East Side 30 Chelsea-Clinton 45 Gramercy Park-Murray Hill 21 Greenwich Village-SoHo 11 Union Square-Lower East Side 66 Lower Manhattan 6 Queens Long Island City-Astoria West Queens Flushing-Clearview Bayside-Little Neck Ridgewood-Forest Hills Fresh Meadows Southwest Queens Jamaica Southeast Queens Rockaway Staten Island Port Richmond Stapleton-St George Willowbrook South Beach-Tottenville 620 44 86 69 19 85 19 60 116 45 69 128 22 36 30 39

Source: NYS DOH, Statewide Planning and Research Cooperative System, 1994-2003 updated April 2004
Rates are calculated using US Census 1990, 2000 and age-standardized to the year 2000 US Standard Population Cells represent 6 persons and are not reported

APXB-6

The New York City Department of Health and Mental Hygiene

Diabetes in New York City: Public Health Burden and Disparities

Appendix B: Neighborhood Tables and Maps

Diabetes mortality by UHF neighborhood, age-adjusted death rate, all ages, New York City, 2002-2003

Deaths per 100,000
79 - 124 125 - 192 193 - 281 282 - 409 410 - 576
301 106 302 303 304 305 306 401 307 402 308 309 310 201 211 202 203 205 501 206 502 503 209 210 207 208 410 204 407 405 408 409 406 403 404 107 101 102 103 105 104

504

Rates are calculated using US Census 2000 and age-standardized to the year 2000 US Standard Population

APXB-7

The New York City Department of Health and Mental Hygiene

Diabetes in New York City: Public Health Burden and Disparities

Appendix B: Neighborhood Tables and Maps

Diabetes mortality by borough and UHF neighborhood, number and age-adjusted death rate, all ages, New York City, 1994-1995 and 2002-2003
UHF Neighborhood
Number of deaths 1994-1995 Age-adjusted death rate/ 100,000 Number of deaths 2002-2003
Age-adjusted death rate/ 100,000 change

101 102 103 104 105 106 107 201 202 203 204 205 206 207 208 209 210 211 301 302 303 304 305 306 307 308 309 310 401 402 403 404 405 406 407 408 409 410 501 502 503 504

Bronx Kingsbridge-Riverdale Northeast Bronx Fordham-Bronx Park Pelham-Throgs Neck Crotona-Tremont Highbridge-Morrisania Hunts Point-Mott Haven

739 52 130 96 143 81 112 79

35 191 306 254 254 423 507 576 242 232 315 370 391 175 157 227 166 156 143 421 233 233 459 568 141 102 178 96 187 222 330 168 175 159 140 100 138 143 202 221 112 131 252 358 216 261 216

816 72 156 125 145 109 122 89 1,091 49 93 209 86 38 86 138 93 76 94 129 590 109 123 91 68 42 42 22 15 67 5 780 49 95 75 21 92 39 116 172 66 52 179 31 44 44 60

372 252 371 353 259 568 532 576 242 261 281 439 409 221 121 314 247 147 116 540 194 247 450 477 141 85 172 79 99 167 89 174 123 124 116 92 152 177 247 324 174 229 214 303 192 247 184

6 32 21 39 2 34 5 0 0 13 -11 19 5 26 -23 38 49 -6 -19 28 -17 6 -2 -16 0 -17 -3 18 47 -25 73 4 -30 -22 -17 8 10 24 22 47 55 75 -15 -15 -11 -5 -15

Brooklyn 1,021 Greenpoint 43 Downtown-Heights-Slope 104 Bedford Stuyvesant171 Crown Heights East New York 82 Sunset Park 29 Borough Park
108 East Flatbush-Flatbush 103 Canarsie-Flatlands 61 Bensonhurst-Bay Ridge 77 Coney Island-Sheepshead Bay 112 Williamsburg-Bushwick 102 Manhattan 690 Washington Heights-Inwood 103 Central HarlemMorningside Heights 131 East Harlem 1020 Upper West Side 68 Upper East Side 53 Chelsea-Clinton 47 Gramercy Park-Murray Hill 27 Greenwich Village-Soho 27 Union Square-Lower East Side 88 Lower Manhattan 16 Queens Long Island City-Astoria West Queens Flushing-Clearview Bayside-Little Neck Ridgewood-Forest Hills Fresh Meadows Southwest Queens Jamaica Southeast Queens Rockaway Staten Island Port Richmond Stapleton-St George Willowbrook South Beach-Tottenville 707 71 117 82 21 84 31 91 110 42 31 180 33 46 37 59

Source: Bureau of Vital Statistics, NYC DOHMH, 1994-1995, 2002-2003 Rates are calculated using US Census 1990, 2000 and age-standardized to the year 2000 US Standard Population Total number of deaths by neighborhood may not equal number of deaths by borough due to residents with missing zip code Mortality rate has a relative standard error 30 and should be interpreted with caution

APXB-8

The New York City Department of Health and Mental Hygiene

Diabetes in New York City: Public
Health Burden and Disparities

referenceS

1 Agency for Healthcare Research and Quality 2005 Healthcare Cost And Utilization Project HCUP Clinical Classifications Software CCS for ICD-9-CM Available at: wwwhcup-usahrqgov/toolssoftware/ccs/ccsjsp Accessed May 30, 2007 2 Agency for Healthcare Research and Quality, US Department of Health and Human Services; 2001 Agency for Healthcare Research Quality Indicators: Guide to Prevention Quality Indicators Rockville, Md; AHRQ Publication No 0-R0203 Available at: wwwqualityindicatorsahrqgov/downloads/pqi/pqi_guide_v31pdf Accessed May 30, 2007 3 Centers for Disease Control and Prevention Behavioral Risk Factor Surveillance System Operational and Users Guide: Version 30 Atlanta, GA; December 12, 2006 Available at: ftp://ftpcdcgov/pub/Data/Brfss/userguidepdf Accessed May 30, 2007 4 Centers for Disease Control and Prevention National Diabetes Fact Sheet: United States, 2003 Atlanta, GA; 2003 Available at: wwwcdcgov/diabetes/pubs/factsheethtm Accessed May 31, 2006 5 Lethbridge-Çejku M, Rose D, Vickerie J Summary Health Statistics for US Adults: National Health Interview Survey, 2004 National Center for Health Statistics Vital Health Stat 10228
2006 Available at: wwwcdcgov/nchs/data/series/sr_10/sr10_228pdf Accessed May 30, 2007 6 National Center for Health Statistics Mortality Data, Multiple Cause-of-Death Public-Use Data Files Rockville, MD; 2006 Available at: wwwcdcgov/nchs/products/elec_prods/subject/mortmcdhtmdescription1 Accessed May 30, 2007 7 National Heart, Lung, and Blood Institute: National Cholesterol Education Program Third Report of the Expert Panel on Detection, Evaluation, and Treatment of High Blood Cholesterol in Adults Adult Treatment Panel III National Institutes of Health NIH Publication No 01-3670 May 2001 Available at: wwwnhlbinihgov/guidelines/cholesterol/ Accessed May 30, 2007 8 New York State Department of Health Statewide Planning and Research Cooperative System SPARCS Albany, NY; 2006 Available at: wwwhealthstatenyus/statistics/sparcs/indexhtm Accessed May 30, 2007 9 US Census Bureau American Community Survey: A Handbook for State and Local Officials Washington, DC: US Census Bureau; 2004 Available at: wwwcensusgov/acs/www/Downloads/ACS04HSLOpdf Accessed May 30, 2007 10 US Census Bureau Current Population Survey, 2004 Annual Social and Economic ASEC Supplement Washington, DC: US Census Bureau;
2004 Available at: wwwcensusgov/apsd/techdoc/cps/cpsmar04pdf Accessed May 30, 2007 11 US Department of Health and Human Services Healthy People 2010: 2nd ed With Understanding and Improving Health and Objectives for Improving Health 2 vols Washington, DC: US Government Printing Office, November 2000 Available at: wwwhealthypeoplegov/document/html/tracking/contentshtm Accessed May 30, 2007 12 US Renal Data System USRDS 2006 Annual Data Report: Atlas of End-Stage Renal Disease in the United States Bethesda, MD; National Institutes of Health, National Institute of Diabetes and Digestive and Kidney Diseases; 2006 Available at: wwwusrdsorg/adrhtm Accessed May 30, 2007

REF-1

The New York City Department of Health and Mental Hygiene

Acknowledgements
Our thanks to the following individuals who provided and/or analyzed data included in this report: Donna Eisenhower, Joe Kennedy, Wen Hui Li, Cari Olson, Tejinder Singh, Xiaowu Lu, Mary Huynh, Qun Jiang, John Jasek NYC DOHMH Division of Epidemiology; Teri Mahotiere IPRO Thanks also to Shadi Chamany, Lorna Thorpe, Lynn Silver and Bonnie Kerker for their careful review of this report

Editorial
Cortnie Lowe, Executive Editor, Bureau of
Communications Lise Millay Stevens, Senior Editor/Writer Deborah Deitcher, Director of Communications, Division of Health Promotion and Disease Prevention

Source:nyc.gov

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